‘She looks after me,’ he said in Malay
The Sunday Times
May 4, 2008
Whither home health care?
Lack of funding and manpower shortage are hampering the industry’s growth
By Radha Basu
Blind, ill and all alone, Mr Jamil Bogel, 79, could have easily found shelter in a nursing home.
But when social workers sought to ward him in late 2005, the tenacious old man fought to stay put. Home is where his heart is.
‘I hate hospitals,’ he told the social workers then.
He still does - and he still lives in his one-room rental flat at Indus Road. But that has helped heal rather than hurt him.
With a doctor and nurse visiting him at regular intervals, the former cleaner - who has acute diabetes, gastric problems and a chronic skin disease - is getting quality care while enjoying the familiar comforts of home.
But Mr Jamil is among a lucky few. Despite Singapore’s growing ranks of grey, home health-care services have yet to become a big success.
Ministry of Health estimates show that there are about 600 patients who regularly receive medical care at home.
That’s just a small fraction given that there are nearly 70,000 people aged 65 and above who either live alone or live with an elderly spouse, though, of course, not all may need the services.
But first, how exactly does home health care help?
In Mr Jamil’s case, the results are tangible. Before Hua Mei Care Management Services took over his case in late 2005, he used to end up in hospital every other month. Since early 2006, however, he has been warded only twice.
A strictly monitored medicine regime - he takes 10 pills every day - has kept the quiet old man in relatively good health.
Thanks to little customised pill boxes - each of a different shape - he knows exactly which dose of medicine to take at which hour by simply feeling the boxes.
The nifty devices were provided by the clinic, which seeks to allow older folk the freedom and dignity of living out their last days at home rather than in a hospital or a nursing home.
Mr Jamil’s wife, a stroke patient, is in a nursing home while his sons, busy eking out a living for their own families, have little contact with him. The clinic’s staff have thus become a surrogate family.
Aside from providing health care, the clinic staff have also arranged to attend to his daily domestic needs, just as a family member would.
When he was first referred to the clinic, his home was in a shambles, recalled social worker Kalyn Foo who manages Mr Jamil’s home- care arrangements.
His flat was dank and dirty, smeared with rotting food and drink stains and even cat poo, from his ageing but beloved pet, Tempot.
Ms Foo referred him to a host of voluntary organisations which provide him cooked meals and escort him to the hospital when necessary.
His flat has also been spruced up. When The Sunday Times visited him recently, the white-tiled floors were spotless and clean blue Barney-print sheets were stretched across his well-worn mattress.
Mr Jamil may not need their services, but the care team at Hua Mei can also hook him up with physiotherapists and occupational therapists who go to patients’ homes to help them fight the debilitating effects of old age and disease.
Such regular physiotherapy sessions, for instance, have enabled housewife Tijar Makban, 82, to regain the use of her legs.
Before she sought home therapy in 2006, crippling osteoarthritis had left her confined to bed. She lives with her grandson, but when he was at work, she would phone a neighbour every time she needed to go to the toilet or wanted to eat something.
‘I tried not to disturb her more than once or twice a day,’ the friendly woman said in Malay. Today, she can walk again and does not need the help of her neighbour.
So what ails the sector? And what more can be done to overcome the problems? The Secretary of the Home Healthcare Association, Dr Ng Wai Chong, attributes the sluggish growth of home health-care services to a lack of funds. Half of the 10 home-health care providers are members of the association.
The Tsao Foundation, which runs the Hua Mei clinic, for instance needs about $8,000 a year to look after each patient at home. Only about a fifth of its funds currently comes from the Government.
‘It would be good if the Ministry of Health can consider allocating more money to home health care and revising the funding model,’ said Dr Ng, who is himself a home-care physician.
Currently, the ministry’s funding is tied to the number of visits a doctor or nurse makes to a home-
bound patient. Therapy services are not funded at all. This should change, in Dr Ng’s view.
‘We are not only talking about acute episodic care provided by doctors, but management of chronic and psychosocial conditions that could require the expertise of therapists and social workers as well,’ he said.
Other home health-care providers such as St Luke’s Hospital and Touch Community Services agree that more state funding is imperative to grow the sector.
Head of medical services at St Luke’s Hospital Tan Boon Yeow said about half of the hospital’s home care patients do not qualify for subsidies since they earn more than $1,000 a month per capita, the ministry’s cut-off level for those who can avail themselves of subsidies.
With each doctor’s visit costing $130, few can afford it. Besides, the use of Medisave is limited for home care, and Medifund - the state kitty which helps meet health-care costs for the destitute - cannot be used at all.
But funding is not the only stumbling block, said Dr Soh Cheng Cheng, assistant director at the Tsao Foundation. There is a shortage of manpower too to provide ’safe and competent care at home’, he said.
‘Most doctors and nurses see home care as less glamorous, less lucrative and physically more demanding than working in hospitals.’
A Monash University study in 2000 has shown how maintaining a patient at home can lead to better quality of life and be cheaper as well, by as much as 40 per cent.
The study looked at nearly 1,000 home-bound patients and compared them to another 1,000 in hospital with similar ailments. Similar studies have also been conducted in the United States.
It would be useful to conduct such studies here too, said Dr Ng, given that Singapore is ageing faster than most societies in the world. Keeping old folk at home will not only help save health-care dollars, but it will also ease the crunch for hospital beds.
Frail, immobile seniors are often the ones who occupy bed space in hospitals and nursing homes.
While no local data exists yet on the effectiveness of home-health services, there is data to show that the number of potential home- health candidates is on the rise.
A National University of Singapore study published in 2006 found that disability rates among elderly were on the rise, in contrast to places like the United States.
Two decades ago, about 14 per cent of those aged 75 and above could not do simple things such as move around, bathe or eat. By the time of the 2006 study, this had risen to 20 per cent.
The issue was brought up in Parliament in March this year when MP Halimah Yacob urged the Health Ministry to rethink its strategy which she said ’seemed to be designed at keeping the elderly in hospital rather than at home’.
Pleading for more government subsidies for home care, she said: ‘One may argue that the elderly stay longer in hospitals because they are more sick, but it could also be because families with little support at home drag their feet in taking them home.’
Responding to queries from The Sunday Times, an MOH spokesman said the ministry would encourage more elderly people to live within the community. ‘We recognise there is a need to improve financial assistance to those who prefer home care. This is being studied.’
The ministry has allocated $1 billion over the next five years to recruit and train doctors, nurses and therapists, the spokesman added.
It is not possible to say exactly how many of them will eventually deal with home health-care services, but whatever the case, it is good news for other frail old folk like Mr Jamil who want to spend their twilight years ensconced at home rather than in a sterile nursing home.
Despite having no family to live with, he is determined to stay home, since leaving would mean separation from his beloved cat Tempot.
One night recently, when Mr Jamil fell in his bathroom, the faithful feline ran next door and meowed plaintively until the neighbour came to her master’s door to see what was wrong.
‘She looks after me,’ he said in Malay, as Tempot sat regally on his well-worn mattress.
‘And I want to be there for her.’
